7th IAS Conference on HIV Pathogenesis, Treatment and Prevention Tracking the HIV/AIDS epidemic in Asia and the Pacific Mr. J.V.R. Prasada Rao UN Secretary General Special Envoy on HIV/AIDS in Asia Pacific 3 July 2013 Kuala Lumpur, Malaysia

1. Epidemic and response 2. Financing AIDS response 3 1. Epidemic and response 2. Financing AIDS response 3. Legal environment 4. HIV/AIDS and post 2015 development agenda

Epidemic and response

State of the epidemic: Global and Asia-Pacific People living with HIV 34,000,000 [31,400,000 – 35,900,000] 4,900,000 [3,900,000 – 6,100,000] Women living with HIV 15,000,000 [13,900,000 – 15,700,000] 1,600,000 [1,200,000 – 2,100,000] New HIV infections 2,500,000 [2,200,000 – 2,800,000] 370,000 [250,000 – 550,000] Adult HIV prevalence 0.8 % [0.7% – 0.8%] 0.2 % [0.2% – 0.2%] AIDS-related deaths 1,700,000 [1,500,000 – 1,900,000] 310,000 [240,000 – 400,000] Source: Prepared by www.aidsdatahub.org based on HIV estimates and projections data for UNAIDS (2012). Global Report: UNAIDS Report on the Global AIDS Epidemic 2012

Epidemic and response: Asia-Pacific and Sub Saharan Africa Type of epidemic Populations affected by AIDS Burden of epidemic Prevention interventions Concentrated among key populations Generalized Sex workers and their clients, Men who have sex with men, Transgender, People who inject drugs, and all of their intimate partners General population: men, women, and young people 4.9 million People living with HIV 370,000 New infections 23.5 million People living with HIV 1.8 million New infections Relatively smaller populations but more difficult to reach due to stigma and legal barriers Larger population sizes but relatively easier to reach

Disease burden: Asia and Sub-Saharan Africa Death (%) 16% 5.6% 3.2% South-East Asia, East Asia, and Oceania South Asia Sub-Saharan Africa Source: http://www.healthmetricsandevaluation.org

New HIV infections in Asia-Pacific region Significant decline in new HIV infections in the last decade, but slow-down between 2008 and 2011 Source: Prepared by www.aidsdatahub.org based on HIV estimates and projections data for UNAIDS (2012). Global Report: UNAIDS Report on the Global AIDS Epidemic 2012

Same is true for countries where the epidemic is slowing down Example of countries with declining new HIV infections The slide shows the examples of countries with declining new infections. However the rate of decline has come down after 2008. Additionally, countries such as Bangladesh, Indonesia, Philippines and Sri Lanka shows more than 25% increase in HIV incidence between 2001 and 2011 Same is true for countries where the epidemic is slowing down Source: Prepared by www.aidsdatahub.org based on HIV estimates and projections data for UNAIDS (2012). Global Report: UNAIDS Report on the Global AIDS Epidemic 2012

Estimated annual new HIV infections by population group, Asian Epidemic Model MSM Unless effective HIV prevention strategies are implemented, the Commission on AIDS in Asia predicts that by 2020 approximately half (46 percent) of all new HIV infections in Asia will be among MSM, an increase of 13 percent from 2008 (Commission on AIDS in Asia 2008).This is typical business as usual scenario That the Commission predictions are coming true is evident from the next two slides. Half of all new infections among MSM by 2020 if ‘business as usual’- Commission on AIDS in Asia Source: Commission on AIDS in Asia. (2008). Redefining Aids in Asia: Crafting an Effective Response.

Rising HIV epidemic among MSM in many regions across the world HIV prevalence among MSM vs. adults Rising HIV epidemic among MSM in many regions across the world Source: Beyrer, C., Baral, S. D., Griensven, F. v., Goodreau, S. M., Chariyalertsak, S., Wirtz, A. L., & Brookmeyer, R. (2012). Global epidemiology of HIV infection in men who have sex with men. Lancet, 380(9839), 367-377.

Key populations reached by prevention services, regional median, 2011 Key populations are central to the epidemic but not enough are reached by prevention services Source: Prepared by www.aidsdatahub.org based on UNAIDS. (2012). Global Report: UNAIDS Report on the Global AIDS Epidemic 2012

Stagnating consistent condom use among MSM - impact on HIV prevalence Proportion of consistent condom use and HIV prevalence among MSM From all these graphs,we can notice consistant condom use among men who have sex with men stagnating for the last 5 years which has its impact on HIV prevalance.This is more pronounced in Thailand where the prevalence levels shot up to 20% in the last 3 years. Stagnating consistent condom use among MSM - impact on HIV prevalence Source: Prepared by www.aidsdatahub.org based on 1) Mishra, R. M., Dube, M., et al. (2012). Changing epidemiology of HIV in Mumbai: an application of the Asian epidemic model. Glob J Health Sci, 4(5), 100-112.; 2) Lan, W., Lu, W., et al. (2012). HIV Prevalence and Influencing Factors Analysis of Sentinel Surveillance among Men who have Sex with Men in China, 2003-2011. Chinese Medical Journal, 125(11), 1857-1861.; 3) Data from UNAIDS Country Office Thailand.

Consistent condom use among female sex workers with their clients On the other hand,high levels of consistant condom use among sex workers has been reported in Thailand,Cambodia and India which resulted in declining infection rates among the sex workers and their clients.This is one of the main reasons for reduction of heterosexual transmission which has a bearing on national incidence levels in a number of Asian countries. Source: Prepared by www.aidsdatahub.org based on 1) Chhorvann, C. (2011). Behavioral Sentinel Surveillance 2010. Power Point Presentation. National Center for HIV/AIDS Dermatology and STD; 2) Thailand UNGASS Report 2010; 3) Erausquin, J. T., Biradavolu, M., et al. (2012). Trends in condom use among female sex workers in Andhra Pradesh, India: the impact of a community mobilisation intervention. J Epidemiol Community Health, 66(2), 2011-200511; 4) Mishra, R. M., Dube, M., et al. (2012). Changing epidemiology of HIV in Mumbai: an application of the Asian epidemic model. Glob J Health Sci, 4(5), 100-112.

Correlation between safe injecting and HIV prevalence among PWID Same is true of safe injecting practices and HIV prevalence among people who use drugs,with contrasting results from Nepal and Pakistan.Nepal is like a best example with consistant use of sterile equipment reported from 97% of PWUDs. * Duration of consistent use of sterile injecting equipment varies from last week to last 6 months; ** Behavioral data for 2006-07, Never used used-needles and syringes; *** Behavioral data for 2008 Source: Prepared by www.aidsdatahub.org based on National HIV Sentinel Surveillance reports, Integrated Biological and Behavioral Surveillance reports and other reports

Prevention of mother-to-child transmission coverage, by region, 2010 and 2011 Middle East and North Africa South and South-East Asia East Asia and Oceania Caribbean Latin America Low- and middle-income countries Sub-Saharan 100 80 60 40 20 % 2011 2010 Only one in five pregnant women living with HIV received effective ART regimens for PMTCT in South and South-East Asia Source: 2012 country progress reports (www.unaids.org/cpr) and UNAIDS estimates.

Progress NOT apparent in eliminating new HIV infections among children Percentage reduction in new HIV infections among children, 2009 to 2011 Progress NOT apparent in eliminating new HIV infections among children Source: Prepared by www.aidsdatahub.org based on UNAIDS. (2012). Global Report: UNAIDS Report on the Global AIDS Epidemic 2012

HIV testing coverage among key populations, regional median, 2011 Though HIV is concentrated among key populations, less than half of them know their HIV status Source: Prepared by www.aidsdatahub.org based on UNAIDS. (2012). Global Report: UNAIDS Report on the Global AIDS Epidemic 2012

Number and proportion of eligible people receiving ART at the end of 2011 1.1 million people are receiving antiretroviral therapy – lagging behind global trend Source: Prepared by www.aidsdatahub.org based on 1)UNAIDS. (2012). Global Report: UNAIDS Report on the Global AIDS Epidemic 2012.; 2) www.aidsinfoonline.org

Correlation between high level of treatment coverage and decline in new infections Prepared by www.aidsdatahub.org based on www.aidsinfoonline.org

HIV-1 drug resistance in ARV-naïve populations SDRM = Surveillance Drug Resistance Mutations As ART coverage continues to grow, there is evidence of drug resistance emerging Source: Stanford University HIV Drug Resistance Database at http://hivdb.stanford.edu/surveillance/map/

Financing AIDS response

Decreasing dependence on external aid Trends in domestic public and international AIDS spending, global and the Asia-Pacific Decreasing dependence on external aid Source: Prepared by www.aidsdatahub.org based on 1) UNAIDS. (2012). Global Report: UNAIDS Report on the Global AIDS Epidemic 2012.; 2) www.aidsinfoonline.org

Investing in AIDS: Shared responsibility in Asia-Pacific HIV expenditure from domestic sources, Asia-Pacific Investing in AIDS: Shared responsibility in Asia-Pacific Source: Prepared by www.aidsdatahub.org based on 1) UNAIDS. (2012). Global Report: UNAIDS Report on the Global AIDS Epidemic 2012.; 2) www.aidsinfoonline.org

AIDS spending in Asia Pacific – low on High Impact Prevention Total AIDS spending and amount spent on key populations prevention programmes AIDS spending in Asia Pacific – low on High Impact Prevention Source: Prepared by www.aidsdatahub.org based on www.aidsinfoonline.org

Legal environment

Adverse legal environment - Why the law matters?

We can see the impact of criminalisation of MSM on prevalence of HIV in this slide.The range is as high as 32% in Zambia where the activity is criminalised to as low as 1% in Cuba which does not criminalise.The Global Commission on HIV and Law has given out clear cut recommendations to improve the legal environment,both laws on the books and laws on the streets it their enforcement and most importantly access to justice for the vulnerable populations.Each country needs to adopt a plan of action to progressively implement judicial reforms which will make the path easy to achieve a HIV free generation.

HIV/AIDS in post 2015 development agenda This will lead us into the future, the post 2015 development agenda and where will HIV/AIDS in the next 15 to 20 years.

Goal 6: Combat HIV/AIDS, malaria and other diseases Millennium Development Goal 6: Global progress by region, 2012 Goal 6: Combat HIV/AIDS, malaria and other diseases Goals and Targets Africa Asia Oceania Latin America & Caribbean Caucasus & Central Asia Northern Sub-Saharan Eastern South-Eastern Southern Western Halt and begin to reverse the spread of HIV/AIDS Low incidence High incidence Halt and reverse the spread of TB Low mortality High mortality Moderate mortality But let us take a look at where the region would be achieving the MDG 6 which calls for halting and reversing the spread of HIV by 2015. This is from the 2012 Millennium Goals Progress Chart. It shows that “Southern” Asia as a region is expected to achieve the millenium targets of halting and reversing the epidemic.This is mainly because of good performance of India,Sri Lanka and Nepal but masks the low performance of other countries in the region. For South East Asia, progress is not enough to achieve the target, if prevailing trends persist ie if business as usual is the approach. The progress chart operates on two levels. The word in each box indicate the present degree of compliance with the target. The colours show progress towards the target according to the legend below: Target already met or expected to be met by 2015. Progress insufficient to reach the target if prevailing trends persist. No progress or deterioration. Sources: Statistics Division, Department of Economic and Social Affairs, United Nations. (2012). Millennium Development Goals: 2012 Progress Chart.

Status of progress towards MDG targets in Asia-Pacific, 2010-11 Country MDG Goal 6 HIV prevalence TB incidence TB prevalence Asia Pacific Cambodia China India Indonesia Lao PDR Malaysia Myanmar Nepal Pakistan Philippines Thailand Viet Nam Early achiever On track Slow Regressing/No progress Source: Prepared by www.aidsdatahub.org based on UNESCAP, ADB, & UNDP. (2012). Accelerating Equitable Achievement of the MDGs : Closing Gaps in Health and Nutrition Outcomes , Asia- Pacific Regional MDG Report 2011/12. Bangkok.

Post 2015 development agenda UNSG’s High Level Panel of Eminent Persons Rio + 20 Conference on Sustainable Development Task Team for Global Thematic Consultation on Health Is HIV/AIDS a priority ? I also want to apprise you about the global dialogue on post 2015 development agenda and where health in general and AIDS in particular will figure in.We are hearing global partners including UNAIDS making a strong pitch for ending AIDS or emergence of an AIDS free world. Two parallel initiatives to define post 2015 development agenda are under way. The intergovernmental working group set up as a follow up of the Rio +20 Conference will be submitting its report to UNGA in September this year.The High Level Panel set up by the Secretary General,United Nations has already submitted its report which is in public domain.Where will AIDS figure in in the post 2015 development agenda is still an open question.

HLP report - Proposed new health MDGs: Post 2015 4a. End preventable infant and under-5 deaths, 4b. Increase by x% the proportion of children, adolescents, at-risk adults and older people that are fully vaccinated 4c. Decrease the maternal mortality ratio to no more than x per 100,000 4d. Ensure universal sexual and reproductive health and rights 4e. Reduce the burden of disease from HIV/AIDS, tuberculosis, malaria, neglected tropical diseases and priority non-communicable diseases But the report of the High Level Panel gives an indication of how the global community looks at AIDS beyond 2015. Of the --- MDGs suggested by the panel,health has five components and the last one among them includes HIV/AIDS which is clubbed with all communicable,non-communicable and neglected tropical diseases and the objective is ‘reduce the burden ‘.

Millennium Development Goal of 2015 MDG on AIDS 2015 and 2030 Millennium Development Goal of 2015 Post 2015 Goal 6: Combat HIV/AIDS, malaria and other diseases 4e. Reduce the burden of disease from HIV/AIDS, tuberculosis, malaria, neglected tropical diseases and priority non-communicable diseases Target 6.A: Have halted by 2015 and begun to reverse the spread of HIV/AIDS Target 6.B: Achieve, by 2010, universal access to treatment for HIV/AIDS for all those who need it Target 6.C: Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases Now,compare this with the MDG 6 targets of 2015 which puts halting and reversing as the major goal for HIV/AIDS.The logical follow up to this should have been to reach elimination goals for HIV and an AIDS free world.But all that the Panel recommends is a general target of reducing the burden.We can still hope that the countries which are affected by AIDS would argue strongly for a tougher target in the world body but the situation is worrying.

Country support in UN General Assembly for a specific MDG for ending AIDS by 2030. Donors and UN agencies need to support the call to end AIDS by 2030. Civil society pressure crucial

Global response to HIV/AIDS is delicately balanced. We need to firmly tilt it towards the goal of elimination.

Thank you